Could the routine pelvic exam — for decades a central element of a woman’s annual visit to her doctor — soon become a thing of the past?
Perhaps. On Monday, the American College of Physicians (ACP) published a new clinical practice guideline that recommends against routine pelvic exams for women who are not pregnant and do not have symptoms of cancer or other illness.
“Available studies show that the yield of pelvic examination for identifying cancer or other treatable disease in nonpregnant women without symptoms is low and is not associated with improved health outcomes,” states a patient summary released with the new guideline. “However, there are many false-positive findings on pelvic examination, and such findings subject patients to unnecessary worry and follow-up.”
“Pelvic examination can cause anxiety, discomfort, pain, and embarrassment, especially in women who have a history of sexual abuse,” the guideline summary adds.
Review of the evidence
Pelvic exams are conducted on an examination table, often with the woman’s feet in stirrups. For the procedure, the doctor does an internal visual exam of the vagina and cervix using a speculum (a hinged instrument shaped like a duck’s bill) as well as a non-visual physical exam of the ovaries, uterus and other pelvic organs using both hands (one inside the vagina, the other on the patient’s abdomen).
The doctor may also take a Pap smear to check for early signs of cervical cancer. Such screenings are no longer routinely given every year, however. Current guidelines recommend that cervical cancer screening begin at age 21 and continue every three years until age 65. The interval can be extended to every five years for women aged 30. Pap tests are not recommended for women over age 65, unless the results from a past test indicate that a woman is at high risk for developing cervical cancer.
The ACP does not recommend any changes to the current Pap smear guidelines.
The ACP came to its current pelvic-exam guideline after a committee of its experts systematically reviewed all the literature on the topic published from 1946 through January 2014.
They concluded that, according to the scientific evidence, routine pelvic exams do not accurately diagnose ovarian cancer — nor do they reduce the death rate from that cancer. The experts also found that the exam “rarely detects noncervical cancer or other treatable conditions and was not associated with improved health outcomes.”
The evidence revealed, however, that routine pelvic exams were associated with many false-positive findings — results that wrongly suggested the presence of disease. These findings can lead to unnecessary surgical procedures, the ACP experts note, as well as “unnecessary fear, anxiety, embarrassment, pain and discomfort.”
“Women with a history of sexual violence, and particularly those with [post-traumatic stress disorder], may experience more pain, discomfort, fear, anxiety, or embarrassment during pelvic examination,” the experts add.
A controversial change
As an editorial accompanying the new guideline points out, this recommendation is sure to be controversial. “Ending such a prevalent practice with widespread support among women’s health providers will be met with formidable challenges,” write Drs. George Sawaya and Vanessa Jacoby, two obstetrician-gynecologists at the University of California, San Francisco, in the editorial. (Neither was involved in drafting the ACP’s new guideline.)
In 2012, another physician organization, the American College of Obstetricians and Gynecologists, issued a “committee opinion” in which it continued to recommend annual pelvic exams in all women aged 21 years and older, even though the authors of the opinion also acknowledged that “no evidence supports or refutes the annual pelvic examination or speculum and bimanual examination for the asymptomatic, low-risk patient.”
“The pelvic examination has held a prominent place in women’s health for many decades and has become more of a ritual than an evidence-based practice,” Saway and Jacoby write. “Regardless of whether the American College of Physicians’ recommendation changes practice among obstetrician-gynecologists, it should prompt champions of this examination to clarify its goals and quantify its benefits and harms.”
“With the current state of evidence, clinicians who continue to offer the examination should at least be cognizant of the uncertainty of benefit and the potential to cause harm through a positive test result and the cascade of events that follow.”
The evidence report supporting the new guideline was published in the ACP’s medical journal, Annals of Internal Medicine, where it can be read in full. You can also download and read the guideline itself on the website.